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GP view: Who are private UTI services in pharmacies aimed at?

“It makes sense for treatment of some minor ailments such as UTIs to be provided by pharmacists”

Not all patients may be willing to pay for private urinary tract infection (UTI) tests in community pharmacies, says GP Toni Hazell

I very rarely prescribe antibiotics over the phone. We need to be prescribing fewer of them and in most cases seeing the patient allows me to assess them in a more reliable way, which often leads to the conclusion that antibiotics aren’t needed. One of the exceptions to this rule is otherwise healthy women who present with symptoms of a urinary tract infection (UTI). This is based on a Public Health England guideline from 2019 stating that if a woman has two out of three symptoms of a UTI (dysuria, nocturia and cloudy urine) there is a 74% risk that she has a bacterial infection and therefore empirical treatment is reasonable.

If there is only one symptom then a dipstick test will help to guide antibiotic use, though we should remember that these tests are not infallible. I have certainly been caught out on more than one occasion when I have used a negative dipstick result to reassure a patient, only to be surprised by the culture result a few days later.

On this background, I was interested to see that some pharmacies offer a private urine dipstick service for women with a suspected UTI. At Day Lewis, patients pay £10 for an initial consultation and dipstick kit, and a further £15 for a follow-up consultation and antibiotics if the test is positive. In July, NHS England rolled out a similar pilot for a service that does not have to be paid for. This follows previous schemes that allowed pharmacists to dispense trimethoprim or nitrofurantoin for symptoms of a UTI under a patient group directive, not always involving a urine dipstick.

It makes sense for treatment of some minor ailments such as UTIs to be provided by pharmacists rather than GPs, although as GPs we need to be careful of the effect that this has on the complexity of our clinics. The traditional 10-minute appointment is only possible because some patients will have simple, quick problems. These balance out the time it takes to see patients with complex mental health and multimorbidity issues that cannot possibly be dealt with in 10 minutes. If pharmacists and nurses are handling all the quick and easy consultations, we may have to rethink how many patients we can see in a surgery.

I will be watching with interest to see how much of a success this private service is. I wonder how happy the general public will be to pay for something like this. NHS England guidance telling GPs not to prescribe medicines that are available over the counter only began to be implemented after NHS England wrote to GPs to reassure them that they would not be in breach of their contract for refusing to prescribe paracetamol.

Will the same patient who is unhappy to pay pennies for a packet of generic paracetamol tablets be willing to hand over £25 to have their UTI tested, even if it is significantly less than the cost of a private GP appointment? Time will tell. I imagine that this private service will end up being focused in areas where there are significant numbers of cash-rich, time-poor individuals who feel that the interruption to their day is worth more than the money they will pay for quicker treatment.

Toni Hazell is a GP based in a practice in London

8 Comments

Kevin Western, Community pharmacist

I am sure your surgery is open the correct hours, tho at many, there may not be a prescriber available. It is certainly true that in many many cases, a patient who contacts the surgery with UTI symptoms will be issued a script for 3 days nitrofurantoin or trimethprim without any form of testing and further investigation assuming the surgery is open when the symptoms begin to become obvious.

The PGD (written and signed off by a Doctor) has various criteria which, while they rely on honesty from the patient, are there to restrict the likelihood of problems caused by the nitrofurantoin or more serious conditions

We have just started the service and while some patients, as you say wont buy paracetamol, some who are time poor and cash comfortable would rather pay and sort it there and then. The Dipstick isnt simply protein and  should be a worthwhile addition to diagnosis.

If you arent sure, why not call in at a Pharmacy that offers it and have a look?Im sure they would be happy to discuss it with you!

Greatly Pedantic Highly Clueless, Senior Management

Just wondering how you'd prescribe nitrofurantoin without knowing the patient's eGFR? Will the pharmacist be able to determine if the patient's had more than three courses of abxs a year for UTIs? Do we know if  the patient is in the early stages of pregnancy before reaching for the trimethoprim? 

E simon, Community pharmacist

So by relieving GPs of the "quick and easy consultations", we are in effect allowing them to focus on quality, rather than quantity, of appointments...

Farmer Cyst, Community pharmacist

To be fair, it's the same in any job.

 

In community it would be like if every script you had to check was illegible/out of stock/interacting etc then it would become a lot more demanding - both mentally and in terms of time. GPs are worried that they'll still be expected to have 10 minute slots, but that each patient will be taking 20 minutes to see.

 

Same thing as if you were told all of the 'awkward scripts' were going to come to your branch - would you trust your regional manager to reduce your script target sufficiently?

Giovanna Forte, Senior Management

The key issue here is that without a midstream urine sample, dipsticks cannot guarantee accuracy because they might respond to specimen contamination, giving a false positive results and leading to unnecessary prescribing. A recent primary care study by Public Health Wales / Cardiff and Vale University has shown that a simple triage system for GP's patients presenting with UTI can result in higher volumes of prompt, accurate diagnoses and prescribing, lower retest rates, lower false-positve rates and more reliable dipstick results. The new system, being rolled out in Wales this year also generates significant cost and resource savings. The key to this success was Peezy Midstream, an 87p urine collection system available through the NHS Supply System,  on prescription and acknowledged by NICE to be the only urine collection method to meet gudelines from PHE UK Standards for Microbiology Investigation of Urine.  The study is on our website at forte-medical.com. Any pharmacies or GP surgeries who would like a couple of samples to look at, please contact us via the website.

Snake Plissken, Student

We have operated this service for over a year. Not sold a single kit. Have had some interest but only from complex patients e.g patients under Urology for recurrent UTIs which exempts them from the service. 

Adam Hall, Community pharmacist

I've looked at this service and, for those women who cannot see a GP when it suits the GP - mostly because they've bogged off early and shut the surgery - there are plenty willing to pay when the 'free at the point of access' service lets them down

Toni Hazell, GP

We are open our full contracted hours. Any GP shutting early on a regular basis would be in deep trouble with the CCG. whether or not our appointment is convenient for the patient depends on their schedule, and it may well be that convenience is something that some will pay for.

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